Professional Documents
Culture Documents
A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock the
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 1 of 4
Close
around a traumatic event. Symptoms revolve around the event and include
reexperiencing of the trauma, psychic numbing, and increased autonomic
arousal.
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A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock the
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 2 of 4
Close
Which of the following is the most appropriate pharmacotherapy for this patient?
/A. CIozapine
/B. Desipramine
/C. FIuoxetine
/D. Haloperidol
/E. Lorazepam
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Explanation - Q: 1.3
Close
A college student is brought to the student health center at the urging of his
roommate. He has been missing class because he needs to
check the room lock many times before he can leave. Once he starts to ride his
bicycle to class, he frequently returns several times to lock th
door. He repeats this ritual every morning and often when he leaves the house.
He misses his appointments and his academic performance
suffers. His hands are chafed.
Question 4 of 4
/C. A man
in the intensive care unit tells his nurse, "You that are the best nurse l
have ever seen-unlike those horrible nurses yesterday who
made me wait for pain medicine. Those nurses were horrible and l never want to
see them again."
/D. A man who is extremely angry with his spouse treats her gently and kindly
/E. A promiscuous man accuses his spouse of being unfaithful to him
Explanation - Q: 1.4
Close
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 1 of 6
Explanation - Q: 2.1
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Which of the following criteria would serve to exclude the most likely diagnosis?
/A. Panic attacks beginning during sleep
/B. Panic attacks beginning while driving
/C. Panic attacks occurring at work and home
/D. Panic attacks occurring "out of the blue"
/E. Panic attacks occurring with caffeine intake
Explanation - Q: 2.2
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Explanation - Q: 2.3
Close
accumulation of acetaldehyde.
Lithium (choice D) is a first line treatment for bipolar disorder, and can be
used to augment antidepressant medicines.
Risperidone (choice D) is an atypical antipsychotic medication with
prominent D2 blockade. It is used to treat psychotic conditions, such as
schizophrenia
A 32-year-old married lawyer presents to the emergency department with a
complaint of "having a heart attack." He explains he was "doing
nothing particular" at home about 45 minutes ago when he began having chest
pain with shortness of breath and nausea. His symptoms
peaked within ten minutes, and he "knew this was the big one." His wife noted he
was "shaking and sweaty." His wife immediately brought
him to the hospitaI. He has no significant past medical history, takes no
medications, and denies substance use. His family medical history is
significant for a paternal grandfather that "died of a massive heart attack" at age
56. Physical examination reveals an anxious diaphoretic
man taking short, shallow breaths. Vital signs, cardiac auscultation, ECG, and
cardiac enzymes are completely normaI. The patient has been
to the emergency department 5 times in the last 6 weeks and apologizes for "the
million dollar workup," but explains "every time it happens l
just know l am doomed to die."
Question 4 of 6
Years later, the patient develops a "fear of flying" and is started in once-weekly
therapy for systematic desensitization. Which of the following
forms of psychotherapy is systematic desensitization?
/A. Behavioral psychotherapy
/B. Cognitive psychotherapy
/C. Family psychotherapy
/D. Group psychotherapy
/E. Psychoanalytic psychotherapy
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Explanation - Q: 2.4
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A full cardiac workup of this patient is most likely to reveal which of the following?
/A. Coronary vasospasm
/B. Ebstein's anomaly
/C. Mitral valve prolapse
/D. Myocarditis
/E. QTc prolongation
Explanation - Q: 2.5
Close
symptoms.
Coronary vasospasm (choice A) occurs with cocaine use and usually
presents with the signs and symptoms of a myocardial infarction (with a
positive urine toxicology screen for cocaine).
Ebstein's anomaly (choice B) is a rare, albeit notorious, congenital defect
associated with prenatal exposure to lithium.
Myocarditis (choice D) has occurred with clozapine, which received a "black
box" warning in the PDR in 2002.
QTc prolongation (choice E) can occur with antipsychotic medicines and
tricyclic antidepressants. Torsades may develop.
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scleral injection, and a dry cough are all associated with cannabis use.
Alprazolam (choice A) may cause sedation, slurred speech, disinhibition and
ataxia. Patients seem "drunken."
Caffeine use (choice B) may initially present with panic attacks, but when
carefully questioned, the patient will report caffeine intake (coffee, tea,
chocolate, cocoa, over-the-counter cold medications) and usually develops
headaches (during withdrawal) from caffeine. Caffeine intoxicated patients
could develop paranoia and tachycardia, but cannabis use explains all the
listed symptoms.
Methamphetamine (choice D) and pseudoephedrine (choice E) are
stimulants. Patients may initially present with panic attacks, and can develop
paranoia and tachycardia, but the additional history of inappropriate laughter
and scleral injection indicates cannabis use. Amphetamine abuse mimics
symptoms of schizophrenia.
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he has pressured and excessive speech. His arrest history indicates possible
previous sexual indiscretions, which are a hallmark of bipolar disorder
(excessive involvement in pleasurable activities that have a high potential for
painful consequences). His pacing indicates psychomotor agitation, also a
hallmark of bipolar disorder. This patient probably has a history of severe
depressive episodes, but the occurrence of a single manic episode allows the
diagnosis of bipolar disorder to be made.
Antisocial personality disorder (choice A) refers to a long-standing pattern of
socially irresponsible behavior that reflects a disregard for the rights of others.
These individuals were formerly called psychopaths, and generally lack a
conscience. Many people with this disorder engage in unlawful acts. The
most pervasive characteristic is a lack of remorse for the harm they cause
others.
Borderline personality disorder (choice C) refers to a lifelong pattern of
unstable affect and self-image with erratic behavior. Borderlines have
interpersonal relationships that are intense, but very unstable ("love-hate"
relationships). They are prone to self-mutilation and the defense mechanism
of splitting. But they have a life of chaos, not a sense of grandeur and power,
so the diagnosis does not fit this case.
Posttraumatic stress disorder (choice D) is an anxiety disorder that develops
surrounding a traumatic event. Symptoms revolve around the event and
include reexperiencing of the trauma, avoidance of associated stimuli,
psychic numbing, and increased autonomic arousal.
While the psychotic symptoms of mania and schizophrenia (choice E) may,
at times, be difficult to distinguish, the grandiose content of this man's
symptoms suggest that he is having a manic episode. Note that his
comments that God does not talk to him can be taken as a denial of auditory
hallucinations.
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Question 2 of 7
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This patient is started on lithium to stabilize his mood. BIood levels of lithium
need to be closely monitored as therapeutic levels are close to
toxic levels. The ratio of toxic dose to therapeutic dose is known as which of the
following?
/A. Fractional elimination constant
/B. Half life
/C. Loading dose
/D. Therapeutic index
/E. Volume of distribution
Explanation - Q: 3.3
Close
The correct answer is D. The therapeutic index of a drug is the ratio of the
toxic dose to therapeutic dose. For a drug with a small therapeutic index, care
must be taken not to overdose the patient. Small, stepwise increases in
dosing can aid in finding the therapeutic dose without experiencing toxicity.
A 30-year-old man is brought to the emergency department by police, who
arrested him because he was in the parking lot of a local malI,
yelling "I am a golden god" as he stepped in front of moving cars. When
questioned about his identity, he talks incessantly in a rapid fashion
and threatens to "unleash God's wrath on those who do not submit." He reports
that he has not slept in a week, and does not need sleep. He
has spent the last week preparing for a secret government mission that only the
president knows about. When asked if he ever hears God
talking to him, he says, "Of course not, I am God!" Police report that he has had
several prior arrests for reckless driving and lewd acts. On
examination, he is disheveled and malodorous. It is nearly impossible to get any
further history, as he rapidly paces about and mutters, "I
must go, I must go" over and over again.
Question 4 of 7
Explanation - Q: 3.4
The correct answer is D. Patients on lithium chronically may develop
iatrogenic hypothyroidism. (Approx. 5% of patients taking the drug > 18
months.) Lithium exerts this effect by interfering with the synthesis and
release of thyroid hormone. Thus any patient experiencing prolonged
Close
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The patient later reaches a steady state level of lithium that produces toxic side
effects. If he decides to discontinue his medication, how long
would it take for his lithium blood levels to reach 25% of his original steady state
levels assuming a half life of 22 hours for lithium?
/A. 11 hours
/B. 22 hours
/C. 33 hours
/D. 44 hours
/E. 55 hours
/F. 66 hours
/G. 77 hours
/H. 88 hours
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Explanation - Q: 3.6
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The correct answer is D. Lithium, like most drugs follows first-order kinetics,
which means a constant percent of the drug is eliminated per unit time. His
drug levels will decrease by 50% every half-life. Therefore, they will be 50%
of original levels after one half-life, 25% after two half-lives, 12.5% after three
half-lives, etc. Two half-lives is 22 x 2 = 44 hours.
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disease) of 90%. (90 of the 100 people who actually developed the condition
were correctly identified by the screening test)
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usually the "life of the party," and may be associated with "creating a scene."
They are not self-destructive, like persons with borderline personality
disorder.
Narcissistic personality disorder (choice D) is characterized by a pervasive
pattern of grandiosity, need for admiration, and lack of empathy. They exhibit
a stable self-image and are not self-destructive like persons with borderline
personality disorder.
Paranoid personality disorder (choice E) is characterized by a pervasive
pattern of distrust and suspiciousness.
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
uestion 2 of 6
The doctor repeatedly reassures the patient that he deserves the best care and
his doctors are working on it. The patient refuses to accept
the reassurance, and begins yelling loudly. The doctor screams at the patient to
be quiet. Later, he says " I Iet him have it, because what he
REALLY needed was some tough love for once." The doctor is using which of the
following defense mechanisms?
/A. Denial
/B. Isolation
/C. Rationalization
/D. Sublimation
/E. Suppression
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Explanation - Q: 4.2
Close
(what the patient needs) for a behavior, is usually employed to avoid being
blamed (e.g., for unprofessional behavior).
Denial (choice A) is usually used to avoid awareness of a painful reality, and
is often seen in patients given the news of a fatal illness, or in patients
confronted about substance abuse.
Isolation (choice B) splits the thought from the feeling, and can be seen
when doctors discuss "interesting cases" or "severe pathology" in completely
intellectual terms.
Sublimation (choice D) is replacing an unacceptable wish with a more
acceptable one. In this example, the doctor might have "taken out his
aggression" in the exercise room.
Suppression (choice E) is consciously deciding to remove an idea or feeling
from awareness. "I'm not going to think about that."
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 3 of 6
Which coping mechanism is illustrated by the statement, "You are the best doctor
ever, the rest of the staff is cold and heartless."?
/A. Denial
/B. Projection
/C. Repression
/D. Splitting
/E. Suppression
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Explanation - Q: 4.3
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This patient is started on trazodone to help with sleep. Common side effects of
trazodone include which of the following?
/A. Drowsiness, dizziness, fatigue, and fatal liver failure
/B. Drowsiness, dizziness, hypertension, and nervousness
/C. Drowsiness, dizziness, hypotension, and priapism
/D. Drowsiness, dizziness, nervousness, and seizures
/E. Drowsiness, nervousness, GI distress and sexual dysfunction
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Explanation - Q: 4.4
Close
The correct answer is C. This question illustrates the fact that many
antidepressant drugs have similar side effects, but often have a certain
particular side effect worth knowing. The clue to choice C (trazodone) is
priapism, a painful sustained erection. It is a medical emergency!
The clue to choice A (nefazodone) is fatal liver failure; this drug now has a
"black box" warning in the PDR.
The clue to choice B (venlafaxine) is hypertension, specifically diastolic
hypertension.
The clue to choice D (bupropion) is seizures. DO NOT give this medicine to
patients at risk for seizures (e.g., metabolic derangement, head injury).
The clues to choice E (any and all SSRIs) are GI distress and sexual
dysfunction, which are very troublesome side effects. Inquire about sexual
dysfunction in all patients taking SSRIs.
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The doctor calls the insurance company to authorize admission for "mood
stabilization." When asked, the patient says he does not want to
harm himself at this point. The insurance company denies authorization for an
inpatient admission. The doctor determines the patient's
presentation is too despondent and hopeless to be safe. The most appropriate
intervention is for the doctor to call the insurance company
back and do which of the following?
/A.
Close
The correct answer is B. The FIRST intervention is for the doctor to calmly
explain the reasoning involved in the assessment.
Choice A is an unnecessary beginning to the conversation; calmly asking for
the supervisor later (if needed) would be the appropriate response.
Choice C is lying. It's illegal, for one. Contacting the attending, the board, the
administrator, etc., may help the doctor get the patient's needs met through
honest means.
Choice D is illegal and unethical, and the doctor will ultimately suffer for
modeling to the patient "we can make deals."
Choice E is a threat and implies coercion, at the very least it could damage
the doctor's professional reputation.
A 25-year-old man presents to the emergency department with multiple
lacerations to both wrists. He says he has a history of "every
diagnosis in the book, Doc." The patient reports several recent stressors,
including being fired from his job after "Iosing it" with a "rotten
customer," financial problems, and a fight with his girlfriend three hours ago.
When asked about suicidal ideation, the patient responds with
"would you want this life?" With permission, the doctor speaks with the man's
psychiatrist. His psychiatrist describes a long-standing pattern
of unstable relationships, career changes, and extreme mood swings with erratic
sleep patterns. The patient has taken multiple overdoses in
the past, usually when his psychiatrist is out of town. After the doctor listens
several minutes to the patient empathetically, the man responds
with multiple compliments, proclaiming the doctor is "the best doctor ever." An
hour later the doctor is summoned by the nurses to again see
the patient. The man is sullen and angry "You don't even care what happens to
me. You never did; none of you do, and you just let me sit here
forever. What kind of lousy doctor are you? You're an embarrassment to your
profession."
Question 6 of 6
The nurse calls to tell the doctor that the patient has taken an overdose in the
emergency department. When the doctor arrives, the patient
has slurred speech and is sedated. Within five minutes the patient is sleeping, his
respiratory rate is 10/min and he responds minimally to
painful stimuli. The family tells the doctor that the man takes clonazepam at
home for nocturnal myoclonus. The most appropriate
pharmacologic intervention is to administer which of the following?
/A. Dextrose
/B. FIumazenil
/C. Naloxone
/D. Naltrexone
/E. Thiamine
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Explanation - Q: 4.6
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Explanation - Q: 5.1
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A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 2 of 5
Which of the following medications is the patient most likely currently taking?
/A. Amitriptyline
/B. Chlorpromazine
/C. FIuoxetine
/D. Lorazepam
/E. Phenelzine
Explanation - Q: 5.2
Close
A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 3 of 5
To gather more details about the patient's current state of mind, which of the
following questions would be most appropriate for the physician
to ask at this time?
/A. " Are you taking your antidepressant medications as your previous doctor
instructed?"
/B. " Have you ever made plans to kill yourself?"
/C. " Is there any history of depression in your family?"
/D. " On a depression scale of one to ten, how depressed do think you feel right
now?"
/E. " On average, how much alcohol do you drink in one day?"
Explanation - Q: 5.3
Close
/A. Acetylcholine
/B. Dopamine
/C. Epinephrine
/D. Norepinephrine
/E. Serotonin
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Explanation - Q: 5.4
Close
A 69-year-old white man visits a physician in the outpatient clinic for the first time.
Over the past 5 months, he reports increasing lethargy,
weight loss, and crying "for no reason." The patient had always been an
optimistic person, but today he feels "detached from everything." He
describes his mood "as if there was a pane of glass between me and the rest of
the world and l don't think I'm going to make it. My family and
friends are like cardboard cutouts." His speech is slow and methodicaI,
punctuated by frequent sighs. The patient has also lost interest in
watching movies, which had been his favorite pastime. He also admits that his
drinking has become a problem over the past few weeks, and
he currently consumes a bottle of white wine every evening. He recently lost his
job and is currently filing for divorce, which would end a
seventeen-year marriage. His son has attention-deficit disorder, for which he is
prescribed amphetamine. The patient was hospitalized for
major depression three years ago. The patient's previous doctor had started him
on a medication, but he is unable to recall the name or
anything about it except that he is not supposed to eat cheese, aged meats, or
chocolate while taking it. On physical examination, the patient
appears emaciated. His abdomen is very distended, with hepatomegaly 3 cm
below the right costal margin. He also has a slight tremor. His
gait is normaI. His latest calcium level is 10.3 mg/dL.
Question 5 of 5
Should this particular patient commit suicide, the likeliest method of suicide is
which of the following?
/A. A drug overdose
/B. By running his car in a closed garage for an extended period of time
/C. Cutting his wrists
/D. Hanging himself
/E. With a firearm
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Explanation - Q: 5.5
Close